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Nieuwoudt C, White SE, Heine RP, Widelock TM. Maternal Sepsis. Clin Obstet Gynecol 2024:00003081-990000000-00169. [PMID: 38967478 DOI: 10.1097/grf.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
Sepsis is the second leading cause of pregnancy-related mortality in the United States. Early recognition, treatment, and escalation of care for the obstetric patient affected by sepsis mitigate the risk of mortality and improve patient outcomes. In this article, we provide an overview of maternal sepsis and address topics of maternal pathophysiology, early warning signs, diagnostic criteria, early goal-directed therapy, and contemporary critical care practices. We also present an overview of common etiologies of maternal sepsis and suggested treatment approaches.
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Affiliation(s)
- Claudia Nieuwoudt
- Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC
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Szabó GV, Szigetváry C, Turan C, Engh MA, Terebessy T, Fazekas A, Farkas N, Hegyi P, Molnár Z. Fluid resuscitation with balanced electrolyte solutions results in faster resolution of diabetic ketoacidosis than with 0.9% saline in adults - A systematic review and meta-analysis. Diabetes Metab Res Rev 2024; 40:e3831. [PMID: 38925619 DOI: 10.1002/dmrr.3831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 02/12/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024]
Abstract
Fluid resuscitation during diabetic ketoacidosis (DKA) is most frequently performed with 0.9% saline despite its high chloride and sodium concentration. Balanced Electrolyte Solutions (BES) may prove a more physiological alternative, but convincing evidence is missing. We aimed to compare the efficacy of 0.9% saline to BES in DKA management. MEDLINE, Cochrane Library, and Embase databases were searched for relevant studies using predefined keywords (from inception to 27 November 2021). Relevant studies were those in which 0.9% saline (Saline-group) was compared to BES (BES-group) in adults admitted with DKA. Two reviewers independently extracted data and assessed the risk of bias. The primary outcome was time to DKA resolution (defined by each study individually), while the main secondary outcomes were changes in laboratory values, duration of insulin infusion, and mortality. We included seven randomized controlled trials and three observational studies with 1006 participants. The primary outcome was reported for 316 patients, and we found that BES resolves DKA faster than 0.9% saline with a mean difference (MD) of -5.36 [95% CI: -10.46, -0.26] hours. Post-resuscitation chloride (MD: -4.26 [-6.97, -1.54] mmoL/L) and sodium (MD: -1.38 [-2.14, -0.62] mmoL/L) levels were significantly lower. In contrast, levels of post-resuscitation bicarbonate (MD: 1.82 [0.75, 2.89] mmoL/L) were significantly elevated in the BES-group compared to the Saline-group. There was no statistically significant difference between the groups regarding the duration of parenteral insulin administration (MD: 0.16 [-3.03, 3.35] hours) or mortality (OR: -0.67 [0.12, 3.68]). Studies showed some concern or a high risk of bias, and the level of evidence for most outcomes was low. This meta-analysis indicates that the use of BES resolves DKA faster than 0.9% saline. Therefore, DKA guidelines should consider BES instead of 0.9% saline as the first choice during fluid resuscitation.
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Affiliation(s)
- Gergő Vilmos Szabó
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Emergency Department, Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
- National Ambulance Service, Budapest, Hungary
- Hungarian Air Ambulance Nonprofit Ltd., Budaörs, Hungary
| | - Csenge Szigetváry
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Caner Turan
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Marie Anne Engh
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Tamás Terebessy
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Orthopaedics, Semmelweis University, Budapest, Hungary
| | - Alíz Fazekas
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Poznan University, Poznan, Poland
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Mozun R, Schlapbach LJ. A Critique of the "Conservative Versus Liberal Oxygenation Targets in Critically Ill Children" Multicenter, Randomized Clinical Trial Published in the Lancet 2024-More on "Less Is More?". Pediatr Crit Care Med 2024; 25:e338-e342. [PMID: 38602435 DOI: 10.1097/pcc.0000000000003519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Rebeca Mozun
- Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
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Sankar J, Das RR, Banothu KK. Fluid resuscitation in children with severe infection and septic shock: a systematic review and meta-analysis. Eur J Pediatr 2024:10.1007/s00431-024-05653-w. [PMID: 38916738 DOI: 10.1007/s00431-024-05653-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 02/09/2024] [Accepted: 06/12/2024] [Indexed: 06/26/2024]
Abstract
This study aimed to evaluate the current evidence on various aspects of fluid therapy such as type, volume, and timing of fluid bolus administration in children with septic shock. Systematic review and meta-analysis of clinical trials including children less than 18 years of age admitted to the pediatric emergency and intensive care unit with severe infection and shock requiring fluid resuscitation. The intervention included balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The primary outcome was mortality rate. Of the 219 citations retrieved, 12 trials (3526 children with severe infection with or without malaria and shock) were included. The pooled results found no significant difference in the mortality rate between groups comparing balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The risk of acute kidney injury (AKI) was significantly less in the BC group compared to the NS group. The certainty of evidence for mortality was of "moderate certainty" in the BC vs NS group, and was of "very low certainty" for the other two groups. CONCLUSIONS The current meta-analysis found no significant difference in the mortality rate between the types of resuscitation fluid, and their speed or volume of administration. However, a significantly decreased risk of AKI was found in the BC group. More evidence is needed regarding the speed and volume of administration of fluid boluses in critically ill children.Prospero registration: CRD42020209066. WHAT IS KNOWN • Balanced crystalloids (BC) may be better than normal saline (NS) for fluid resuscitation in critically ill children. WHAT IS NEW • BC are better than NS for fluid resuscitation in critically ill children as they decrease AKI and hyperchloremia.
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Affiliation(s)
- Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India.
| | - Rashmi Ranjan Das
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, 751019, India
| | - Kiran Kumar Banothu
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
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Arabi YM, Belley-Cote E, Carsetti A, De Backer D, Donadello K, Juffermans NP, Hammond N, Laake JH, Liu D, Maitland K, Messina A, Møller MH, Poole D, Mac Sweeney R, Vincent JL, Zampieri FG, AlShamsi F. European Society of Intensive Care Medicine clinical practice guideline on fluid therapy in adult critically ill patients. Part 1: the choice of resuscitation fluids. Intensive Care Med 2024; 50:813-831. [PMID: 38771364 DOI: 10.1007/s00134-024-07369-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/20/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on resuscitation fluids in adult critically ill patients. This part addresses fluid choice and the other two will separately address fluid amount and fluid removal. METHODS This guideline was formulated by an international panel of clinical experts and methodologists. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision. RESULTS For volume expansion, the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general (moderate certainty of evidence), in patients with sepsis (moderate certainty of evidence), in patients with acute respiratory failure (very low certainty of evidence) and in patients in the perioperative period and patients at risk for bleeding (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis (very low certainty of evidence). The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general (low certainty of evidence), in patients with sepsis (low certainty of evidence) and in patients with kidney injury (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using isotonic crystalloids rather than small-volume hypertonic crystalloids in critically ill patients in general (very low certainty of evidence). CONCLUSIONS This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Emilie Belley-Cote
- Divisions of Cardiology and Critical Care, McMaster University, Riyadh, Saudi Arabia
| | - Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, Verona, Italy
- Anaesthesia and Intensive Care B Unit, AOUI-University Hospital Integrated Trust of Verona, Verona, Italy
| | - Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health and UNSW, Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Kathryn Maitland
- Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK
| | - Antonio Messina
- IRCCS Humanitas Research Hospital, Department of Anesthesia and Intensive Care Medicine, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, København, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | - Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Fernando G Zampieri
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Fayez AlShamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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Scurt FG, Bose K, Mertens PR, Chatzikyrkou C, Herzog C. Cardiac Surgery-Associated Acute Kidney Injury. KIDNEY360 2024; 5:909-926. [PMID: 38689404 PMCID: PMC11219121 DOI: 10.34067/kid.0000000000000466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/26/2024] [Indexed: 05/02/2024]
Abstract
AKI is a common and serious complication of cardiac surgery that has a significant impact on patient morbidity and mortality. The Kidney Disease Improving Global Outcomes definition of AKI is widely used to classify and identify AKI associated with cardiac surgery (cardiac surgery-associated AKI [CSA-AKI]) on the basis of changes in serum creatinine and/or urine output. There are various preoperative, intraoperative, and postoperative risk factors for the development of CSA-AKI which should be recognized and addressed as early as possible to expedite its diagnosis, reduce its occurrence, and prevent or ameliorate its devastating complications. Crucial issues are the inaccuracy of serum creatinine as a surrogate parameter of kidney function in the perioperative setting of cardiothoracic surgery and the necessity to discover more representative markers of the pathophysiology of AKI. However, except for the tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ratio, other diagnostic biomarkers with an acceptable sensitivity and specificity are still lacking. This article provides a comprehensive review of various aspects of CSA-AKI, including pathogenesis, risk factors, diagnosis, biomarkers, classification, prevention, and treatment management.
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Affiliation(s)
- Florian G. Scurt
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katrin Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Peter R. Mertens
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christos Chatzikyrkou
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Carolin Herzog
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Liu Y, Zhang J, Xu X, Zou X. Comparison of balanced crystalloids versus normal saline in patients with diabetic ketoacidosis: a meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne) 2024; 15:1367916. [PMID: 38836222 PMCID: PMC11148269 DOI: 10.3389/fendo.2024.1367916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/03/2024] [Indexed: 06/06/2024] Open
Abstract
Purpose The optimal resuscitative fluid for patients with diabetic ketoacidosis (DKA) remains controversial. Therefore, our objective was to assess the effect of balanced crystalloids in contrast to normal saline on clinical outcomes among patients with DKA. Methods We searched electronic databases for randomized controlled trials comparing balanced crystalloids versus normal saline in patients with DKA, the search period was from inception through October 20th, 2023. The outcomes were the time to resolution of DKA, major adverse kidney events, post-resuscitation chloride, and incidence of hypokalemia. Results Our meta-analysis encompassed 11 trials, incorporating a total of 753 patients with DKA. There was no significant difference between balanced crystalloids and normal saline group for the time to resolution of DKA (MD -1.49, 95%CI -4.29 to 1.31, P=0.30, I2 = 65%), major adverse kidney events (RR 0.88, 95%CI 0.58 to 1.34, P=0.56, I2 = 0%), and incidence of hypokalemia (RR 0.80, 95%CI 0.43 to 1.46, P=0.46, I2 = 56%). However, there was a significant reduction in the post-resuscitation chloride (MD -3.16, 95%CI -5.82 to -0.49, P=0.02, I2 = 73%) among patients received balanced crystalloids. Conclusion Among patients with DKA, the use of balanced crystalloids as compared to normal saline has no effect on the time to resolution of DKA, major adverse kidney events, and incidence of hypokalemia. However, the use of balanced crystalloids could reduce the post-resuscitation chloride. Systematic review registration https://osf.io, identifier c8f3d.
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Affiliation(s)
- Yuting Liu
- Oncology and Chemotherapy Department, Lishui People’s Hospital, Lishui, China
| | - Jianfeng Zhang
- Department of Orthopedics, Yunhe People’s Hospital, Lishui, China
| | - Xiaoya Xu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Xiaoyun Zou
- Department of General Practice, Lishui Central Hospital, Lishui, China
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Moran JL, Linden A. Problematic meta-analyses: Bayesian and frequentist perspectives on combining randomized controlled trials and non-randomized studies. BMC Med Res Methodol 2024; 24:99. [PMID: 38678213 PMCID: PMC11056075 DOI: 10.1186/s12874-024-02215-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/10/2024] [Indexed: 04/29/2024] Open
Abstract
PURPOSE In the literature, the propriety of the meta-analytic treatment-effect produced by combining randomized controlled trials (RCT) and non-randomized studies (NRS) is questioned, given the inherent confounding in NRS that may bias the meta-analysis. The current study compared an implicitly principled pooled Bayesian meta-analytic treatment-effect with that of frequentist pooling of RCT and NRS to determine how well each approach handled the NRS bias. MATERIALS & METHODS Binary outcome Critical-Care meta-analyses, reflecting the importance of such outcomes in Critical-Care practice, combining RCT and NRS were identified electronically. Bayesian pooled treatment-effect and 95% credible-intervals (BCrI), posterior model probabilities indicating model plausibility and Bayes-factors (BF) were estimated using an informative heavy-tailed heterogeneity prior (half-Cauchy). Preference for pooling of RCT and NRS was indicated for Bayes-factors > 3 or < 0.333 for the converse. All pooled frequentist treatment-effects and 95% confidence intervals (FCI) were re-estimated using the popular DerSimonian-Laird (DSL) random effects model. RESULTS Fifty meta-analyses were identified (2009-2021), reporting pooled estimates in 44; 29 were pharmaceutical-therapeutic and 21 were non-pharmaceutical therapeutic. Re-computed pooled DSL FCI excluded the null (OR or RR = 1) in 86% (43/50). In 18 meta-analyses there was an agreement between FCI and BCrI in excluding the null. In 23 meta-analyses where FCI excluded the null, BCrI embraced the null. BF supported a pooled model in 27 meta-analyses and separate models in 4. The highest density of the posterior model probabilities for 0.333 < Bayes factor < 1 was 0.8. CONCLUSIONS In the current meta-analytic cohort, an integrated and multifaceted Bayesian approach gave support to including NRS in a pooled-estimate model. Conversely, caution should attend the reporting of naïve frequentist pooled, RCT and NRS, meta-analytic treatment effects.
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Affiliation(s)
- John L Moran
- The Queen Elizabeth Hospital, Woodville, SA, 5011, Australia.
| | - Ariel Linden
- Department of Medicine, School of Medicine, University of California, San Francisco, USA
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Poh K, Bustam A, Hasan MS, Mohd Yunos N, Cham CY, Lim FJ, Ahmad Zahedi AZ, Zambri A, Noor Azhar M. Isotonic balanced fluid versus 0.9% saline in patients with moderate to severe traumatic brain injury: A double-blinded randomised controlled trial. Am J Emerg Med 2024; 77:106-114. [PMID: 38118385 DOI: 10.1016/j.ajem.2023.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Traumatic brain injury (TBI) is a global health concern with significant economic impact. Optimal fluid therapy aims to restore intravascular volume, maintain cerebral perfusion pressure and blood flow, thus preventing secondary brain injury. While 0.9% saline (NS) is commonly used, concerns about acid-base and electrolyte imbalance and development of acute kidney injury (AKI) lead to consideration of balanced fluids as an alternative. OBJECTIVES This study aimed to compare the outcomes of patients with moderate to severe TBI treated with Sterofundin (SF) versus NS. DESIGN, SETTINGS AND PARTICIPANTS A double-blinded randomised controlled trial of patients aged 18 to 65 years with TBI was conducted at the University Malaya Medical Centre from February 2017 to November 2019. INTERVENTION OR EXPOSURE Patients were randomly assigned to receive either NS or SF. The study fluids were administered for 72 h as continuous infusions or boluses. Participants, investigators, and staff were blinded to the fluid type. OUTCOMES MEASURE AND ANALYSIS The primary outcome was in-hospital mortality. Relative risk (RR) with 95% confidence interval (CI) was calculated. MAIN RESULTS A total of 70 patients were included in the analysis, with 38 in the NS group and 32 in the SF group. The in-hospital mortality rate were 3 (7.9%) in the NS group vs. 4 (12.5%) in the SF group, RR = 1.29 (95% CI, 0.64 to 2.59; p = 0.695). No patients developed AKI and required renal replacement therapy. ICP on day 3 was significantly higher in the SF group (18.60 ± 9.26) compared to 12.77 ± 3.63 in the NS group, (95% CI, -11.46 to 0.20; p = 0.037). There were no significant differences in 3-day biochemical parameters and cerebral perfusion pressure, ventilator-free days, length of ICU stay, or Glasgow Outcome Scale-Extended (GOS-E) score at 6 months. CONCLUSIONS In patients with moderate to severe TBI, the use of SF was not associated with reduced in-hospital mortality, development of AKI, or improved 6-month GOS-E when compared to NS.
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Affiliation(s)
- Khadijah Poh
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Aida Bustam
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Nor'azim Mohd Yunos
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Chun Yoong Cham
- Division of Neurosurgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Fang Jen Lim
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | | | - Aliyah Zambri
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Muhaimin Noor Azhar
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.
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10
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Messmer AS, Pfortmueller CA. Normal saline versus balanced crystalloids: is it all about sodium? THE LANCET. RESPIRATORY MEDICINE 2024; 12:187-188. [PMID: 38043565 DOI: 10.1016/s2213-2600(23)00416-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Anna S Messmer
- Department of Intensive Care, Inselspital, University Hospital and University of Bern, 3010 Bern, Switzerland
| | - Carmen A Pfortmueller
- Department of Intensive Care, Inselspital, University Hospital and University of Bern, 3010 Bern, Switzerland.
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11
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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Saner FH, Raptis DA, Alghamdi SA, Malagó MM, Broering DC, Bezinover D. Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure. J Clin Med 2024; 13:506. [PMID: 38256640 PMCID: PMC10816826 DOI: 10.3390/jcm13020506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/07/2024] [Accepted: 01/14/2024] [Indexed: 01/24/2024] Open
Abstract
Acute-on-chronic liver failure (ACLF) refers to the deterioration of liver function in individuals who already have chronic liver disease. In the setting of ACLF, liver damage leads to the failure of other organs and is associated with increased short-term mortality. Optimal medical management of patients with ACLF requires implementing complex treatment strategies, often in an intensive care unit (ICU). Failure of organs other than the liver distinguishes ACLF from other critical illnesses. Although there is growing evidence supporting the current approach to ACLF management, the mortality associated with this condition remains unacceptably high. In this review, we discuss considerations for ICU care of patients with ACLF and highlight areas for further research.
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Affiliation(s)
- Fuat H. Saner
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dimitri A. Raptis
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Saad A. Alghamdi
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Massimo M. Malagó
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dieter C. Broering
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Tyree B, Bock C. Role of Fluid Stewardship in the Critically Ill. AACN Adv Crit Care 2023; 34:273-279. [PMID: 38033208 DOI: 10.4037/aacnacc2023173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Brittany Tyree
- Brittany Tyree is Clinical Pharmacist, Surgery, Department of Pharmacy Services, University of Kentucky HealthCare Chandler Medical Center, 1000 S Limestone, Lexington, KY 40536
| | - Czarina Bock
- Czarina Bock is Clinical Pharmacist, Cardiovascular, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida
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Lee H, Kim JT. Pediatric perioperative fluid management. Korean J Anesthesiol 2023; 76:519-530. [PMID: 37073521 PMCID: PMC10718623 DOI: 10.4097/kja.23128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 04/20/2023] Open
Abstract
The purpose of perioperative fluid management in children is to maintain adequate volume status, electrolyte level, and endocrine system homeostasis during the perioperative period. Although hypotonic solutions containing glucose have traditionally been used as pediatric maintenance fluids, recent studies have shown that isotonic balanced crystalloid solutions lower the risk of hyponatremia and metabolic acidosis perioperatively. Isotonic balanced solutions have been found to exhibit safer and more physiologically appropriate characteristics for perioperative fluid maintenance and replacement. Additionally, adding 1-2.5% glucose to the maintenance fluid can help prevent children from developing hypoglycemia as well as lipid mobilization, ketosis, and hyperglycemia. The fasting time should be as short as possible without compromising safety; recent guidelines have recommended that the duration of clear fluid fasting be reduced to 1 h. The ongoing loss of fluid and blood as well as the free water retention induced by antidiuretic hormone secretion are unique characteristics of postoperative fluid management that must be considered. Reducing the infusion rate of the isotonic balanced solution may be necessary to avoid dilutional hyponatremia during the postoperative period. In summary, perioperative fluid management in pediatric patients requires careful attention because of the limited reserve capacity in this population. Isotonic balanced solutions appear to be the safest and most beneficial choice for most pediatric patients, considering their physiology and safety concerns.
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Affiliation(s)
- Hyungmook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Cheruku SR, Raphael J, Neyra JA, Fox AA. Acute Kidney Injury after Cardiac Surgery: Prediction, Prevention, and Management. Anesthesiology 2023; 139:880-898. [PMID: 37812758 PMCID: PMC10841304 DOI: 10.1097/aln.0000000000004734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Acute kidney injury (AKI) is a common complication in cardiac surgery patients, with a reported incidence of 20 to 30%. The development of AKI is associated with worse short- and long-term mortality, and longer hospital length of stay. The pathogenesis of cardiac surgery-associated AKI is poorly understood but likely involves an interplay between preoperative comorbidities and perioperative stressors. AKI is commonly diagnosed by using increases in serum creatinine or decreased urine output and staged using a standardized definition such as the Kidney Disease Improving Global Outcomes classification. Novel biomarkers under investigation may provide earlier detection and better prediction of AKI, enabling mitigating therapies early in the perioperative period. Recent clinical trials of cardiac surgery patients have demonstrated the benefit of goal-directed oxygen delivery, avoidance of hyperthermic perfusion and specific fluid and medication strategies. This review article highlights both advances and limitations regarding the prevention, prediction, and treatment of cardiac surgery-associated AKI.
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Affiliation(s)
- Sreekanth R Cheruku
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jacob Raphael
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Javier A Neyra
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amanda A Fox
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas; McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, Texas
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Sankar J, Muralidharan J, Lalitha AV, Rameshkumar R, Pathak M, Das RR, Nadkarni VM, Ismail J, Subramanian M, Nallasamy K, Dev N, Kumar UV, Kumar K, Sharma T, Jaravta K, Thakur N, Aggarwal P, Jat KR, Kabra SK, Lodha R. Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial. Crit Care Med 2023; 51:1449-1460. [PMID: 37294145 DOI: 10.1097/ccm.0000000000005952] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock. DESIGN Parallel-group, blinded multicenter trial. SETTING PICUs of four tertiary care centers in India from 2017 to 2020. PATIENTS Children up to 15 years of age with septic shock. METHODS Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality. INTERVENTIONS MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days. MEASUREMENTS AND MAIN RESULTS The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups. CONCLUSIONS Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.
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Affiliation(s)
- Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jayashree Muralidharan
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - A V Lalitha
- Department of Pediatrics Intensive Care, St Johns' Medical College Bengaluru, India
| | | | - Mona Pathak
- Research and Development Department, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | | | - Vinay M Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Javed Ismail
- Pediatric Intensive Care Unit, NMC Royal Hospital Khalifa City, Abu Dhabi, United Arab Emirates
| | - Mahadevan Subramanian
- Division of Pediatric Critical Care, Department of Pediatrics, JIPMER, Puducherry, India
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - Nishanth Dev
- Department of Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - U Vijay Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kiran Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Taniya Sharma
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kanika Jaravta
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Thakur
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | | | - Kana Ram Jat
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Wang P, Huang Y, Li J, Cao D, Chen B, Chen Z, Li J, Wang R, Liu L. Balanced crystalloid solutions versus normal saline in intensive care units: a systematic review and meta-analysis. Int Urol Nephrol 2023; 55:2829-2844. [PMID: 37017820 PMCID: PMC10560196 DOI: 10.1007/s11255-023-03570-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/20/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Intravenous fluid therapy is important for pediatric and adult patients in intensive care units (ICUs). However, medical professionals continue to struggle to determine the most appropriate fluids to obtain the best possible outcomes for each patient. OBJECTIVE We conducted a meta-analysis involving cohort studies and randomized controlled trials (RCTs) to compare the influence of balanced crystalloid solutions and normal saline among patients in ICUs. PATIENTS AND METHODS Studies that compared balanced crystalloid solutions and saline in ICU patients from databases including PubMed, Embase, Web of Science, and Cochrane Library were systematically searched up to July 25, 2022. The primary outcomes were mortality and renal-related outcomes, which included major adverse kidney events within 30 days (MAKE30), acute kidney injury (AKI), new receipt of renal replacement therapy (RRT), maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline. Service utilization including length of hospital stay, ICU stay, ICU-free days and ventilator-free days were also reported. RESULTS A total of 13 studies (10 RCTs and 3 cohort studies) involving 38,798 patients in ICUs met the selection criteria. Our analysis revealed that each subgroup had no significant difference in mortality outcomes among ICU patients between balanced crystalloid solutions and normal saline. A significant difference was detected between the adult groups (odds ratio [OR], 0.92; 95% confidence interval [CI], [0.86, 1.00]; p = 0.04) indicating that the AKI in the balanced crystalloid solutions group was lower than that in the normal saline group. Other renal-related outcomes, such as MAKE30, RRT, maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline showed no significant difference between the two groups. Regarding secondary outcomes, the balanced crystalloid solution group had a longer ICU stay time (WMD, 0.02; 95% CI, [0.01, 0.03]; p = 0.0004 and I2 = 0%; p = 0.96) than the normal saline group among adult patients. Furthermore, children treated with balanced crystalloid solution had a shorter hospital stay time (WMD, - 1.10; 95% CI, [- 2.10, - 0.10]; p = 0.03 and I2 = 17%; p = 0.30) than those treated with saline. CONCLUSIONS Compared with saline, balanced crystalloid solutions could not reduce the risk of mortality and renal-related outcomes, including MAKE30, RRT, maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline, but the solutions may reduce total AKI incidence among adult patients in ICUs. For service utilization outcomes, balanced crystalloid solutions were associated with a longer length of ICU stay in the adult group and shorter length of hospital stay in the pediatric group.
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Affiliation(s)
- Puze Wang
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Yin Huang
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Jin Li
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Dehong Cao
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Bo Chen
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Zeyu Chen
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Jinze Li
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Ruyi Wang
- Department of Urology, West China Hospital of Medicine, Chengdu, China
- Department of Urology, Hospital of Chengdu University, Chengdu, China
| | - Liangren Liu
- Department of Urology, West China Hospital of Medicine, Chengdu, China.
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19
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Chen Y, Gao Y. Comparison of Balanced Crystalloids versus Normal Saline in Critically Ill Patients: A Systematic Review with Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials. Ther Clin Risk Manag 2023; 19:783-799. [PMID: 37850070 PMCID: PMC10577264 DOI: 10.2147/tcrm.s416785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/25/2023] [Indexed: 10/19/2023] Open
Abstract
Background Fluid resuscitation is routinely needed for critically ill patients. However, the optimal choice between crystalloids and normal saline is in heat debate. Objective To conduct a meta-analysis comparing normal saline and balanced crystalloids in the treatment of critically ill patients with composite mortality as the primary outcome. Methods PubMed, Embase, Medline, Web of Science, and Cochrane Library were searched from inception up to March 2022. Studies of critically ill adult patients assigned to receive normal saline or balanced crystalloids were included. We conducted a meta-analysis using an inverse variance, random-effects model in addition to trial sequential analysis (TSA). The primary outcome was composite mortality. Subgroup analyses were also conducted. Results Eighteen full-text studies (n=36,224) were included. Balanced crystalloids were associated with lower mortality compared with normal saline (risk ratio [RR]=0.96; 95% confidential interval [CI] 0.93, 1; p=0.03; I2=0) and lower incidence of acute kidney injury/acute renal failure (RR =0.93; 95% CI = 0.87, 0.99; p=0.03). No significant difference was observed in other outcomes. In the sepsis patients, the balanced crystalloid showed a lower composite mortality rate compared with normal saline (RR =0.91; 95% CI = 0.85, 0.99; p=0.02). TSA analysis demonstrated that, with 80% power, the effect of balanced crystalloid is not larger than a 10% relative decrease in composite mortality compared with normal saline. Conclusion and Relevance This study demonstrated that balanced crystalloids could be an optimal choice over normal saline in critically ill patients to a reduced composite mortality rate. In patients with sepsis, the difference is especially significant. Nonetheless, the optimal resuscitation fluid option between saline and balanced crystalloid solutions should be investigated further with more evidence.
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Affiliation(s)
- Yi Chen
- Emergency Department of West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Institute of Disaster Medicine, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Nursing Key Laboratory of Sichuan Province, Chengdu City, Sichuan Province, People’s Republic of China
| | - Yongli Gao
- Emergency Department of West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Institute of Disaster Medicine, Sichuan University, Chengdu City, Sichuan Province, People’s Republic of China
- Nursing Key Laboratory of Sichuan Province, Chengdu City, Sichuan Province, People’s Republic of China
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Ergezen S, Wiegers EJ, Klijn E, van der Jagt M. Fluid therapy in the acute brain injured patient. Minerva Anestesiol 2023; 89:936-944. [PMID: 37822149 DOI: 10.23736/s0375-9393.23.17328-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Adequate fluid therapy in the acute brain injured (ABI) patient is essential for maintaining an adequate brain and systemic physiology and preventing intra- and extracranial complications. The target of euvolemia, implying avoidance of both hypovolemia and fluid overloading (or "hypervolemia," by definition associated with fluid extravasation leading to tissue edema) is of key importance. Primary brain injury can be aggravated by secondary brain injury and systemic deterioration through diverse pathways which can challenge appropriate fluid management, e.g. neuroendocrine and electrolyte disorders, stress cardiomyopathy (also known as cardiac stunning) and neurogenic pulmonary edema. This is an updated expert opinion aiming to provide a practical overview on fluid therapy in the ABI patient, partly based on more recent work and stressing the fact that intravenous fluids should be regarded as drugs, with their inherent potential for both benefit and (unintended) harm.
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Affiliation(s)
- Saliha Ergezen
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands -
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands -
| | - Eveline J Wiegers
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eva Klijn
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
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Ripollés-Melchor J, Colomina MJ, Aldecoa C, Clau-Terre F, Galán-Menéndez P, Jiménez-López I, Jover-Pinillos JL, Lorente JV, Monge García MI, Tomé-Roca JL, Yanes G, Zorrilla-Vaca A, Escaraman D, García-Fernández J. A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the fluid therapy and hemodynamic monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:458-466. [PMID: 37669701 DOI: 10.1016/j.redare.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/22/2022] [Indexed: 09/07/2023]
Abstract
In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.
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Affiliation(s)
| | - M J Colomina
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario de Bellvitge, Universidad de Barcelona, Barcelona, Spain
| | - C Aldecoa
- Grupo Español de Rehabilitación Multimodal (ReDGERM), Zaragoza, Spain; Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Río Hortega, Valladolid, Spain
| | - F Clau-Terre
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - P Galán-Menéndez
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - I Jiménez-López
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J L Jover-Pinillos
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen de los Lirios, Alcoy, Spain
| | - J V Lorente
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - M I Monge García
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Jerez de la Frontera, Cádiz, Spain
| | - J L Tomé-Roca
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - G Yanes
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - A Zorrilla-Vaca
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Brigham and Women's Hospital, Boston, MA, United States
| | - D Escaraman
- Centro Médico Nacional La Raza, Mexico City, Mexico
| | - J García-Fernández
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Puerta de Hierro, Majadahonda, Spain
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Kamath S, Hammad Altaq H, Abdo T. Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades? Microorganisms 2023; 11:2231. [PMID: 37764075 PMCID: PMC10537306 DOI: 10.3390/microorganisms11092231] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.
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Affiliation(s)
| | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center, The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (S.K.); (H.H.A.)
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Vignarajah M, Berg A, Abdallah Z, Arora N, Javidan A, Pitre T, Fernando SM, Spence J, Centofanti J, Rochwerg B. Intraoperative use of balanced crystalloids versus 0.9% saline: a systematic review and meta-analysis of randomised controlled studies. Br J Anaesth 2023; 131:463-471. [PMID: 37455198 DOI: 10.1016/j.bja.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/29/2023] [Accepted: 05/24/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND The evidence regarding optimal crystalloid use in the perioperative period remains unclear. As the primary aim of this study, we sought to summarise the data from RCTs examining whether use of balanced crystalloids compared with 0.9% saline (saline) leads to differences in patient-important outcomes. METHODS We searched Ovid MEDLINE, Embase, the Cochrane library, and Clinicaltrials.gov, from inception until December 15, 2022, and included RCTs that intraoperatively randomised adult participants to receive either balanced fluids or saline. We pooled data using a random-effects model and present risk ratios (RRs) or mean differences (MDs), along with 95% confidence intervals (CIs). We assessed individual study risk of bias using the modified Cochrane tool, and certainty of evidence using GRADE. RESULTS Of 5959 citations, we included 38 RCTs (n=3776 patients). Pooled analysis showed that intraoperative use of balanced fluids compared with saline had an uncertain effect on postoperative mortality analysed at the longest point of follow-up (RR 1.51, 95% CI: 0.42-5.36) and postoperative need for renal replacement therapy (RR 0.95, 95% CI: 0.56-1.59), both very low certainty. Furthermore, use of balanced crystalloids probably leads to a higher postoperative serum pH (MD 0.05, 95% CI: 0.04-0.06), moderate certainty. CONCLUSIONS Use of balanced crystalloids, compared with saline, in the perioperative setting has an uncertain effect on mortality and need for renal replacement therapy but probably improves postoperative acid-base status. Further research is needed to determine whether balanced crystalloid use affects patient-important outcomes. CLINICAL TRIAL REGISTRATION CRD42022367593.
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Affiliation(s)
| | - Annie Berg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zahra Abdallah
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Naman Arora
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Arshia Javidan
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jessica Spence
- Department of Anaesthesia, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John Centofanti
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Anaesthesia, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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Crowe S. Understanding nursing perceptions of intravenous fluid management practices. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S36-S40. [PMID: 37495415 DOI: 10.12968/bjon.2023.32.14.s36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
PURPOSE Intravenous (IV) fluids are routinely used in hospitalized patients. As IV fluids are an everyday occurrence, their importance is often overlooked. Many patients receive large volumes of fluid during resuscitation to aid in the promotion of tissue perfusion. Nurses regularly administer IV fluids as part of maintenance infusions or as life-saving therapies and, therefore, need to understand these fluids' impact on their patients. Understanding nurses' existing perceptions of IV fluid management practices are crucial to improving practice. METHODS This study used an online survey to gather information on nursing perceptions of IV fluids. Four hundred and sixty-two Canadian nurses from diverse backgrounds were surveyed, including registered nurses, licensed practical nurses and student nurses. RESULTS The study found that the majority of participants agreed that IV fluids, including type, amount, and rationale for infusion, were important. They also agreed that fluids could impact patient outcomes. However, the study found that, despite recognizing the value and importance of fluid management, many nurses struggled with recognizing how to determine a patient's fluid status versus fluid responsiveness. CONCLUSION This study supports improving nursing education to understand better the differences between fluid volume status and volume responsiveness. Our study also provides evidence that nurses need access to more sophisticated tools to conduct dynamic assessments and better meet patients' needs.
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Affiliation(s)
- Sarah Crowe
- Critical Care, Surrey Memorial Hospital, Fraser Health, 13750 - 96th Avenue, Surrey, BC, V3V 1Z2, Canada
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25
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Tamzil R, Yaacob N, Noor NM, Baharuddin KA. Comparing the clinical effects of balanced electrolyte solutions versus normal saline in managing diabetic ketoacidosis: A systematic review and meta-analyses. Turk J Emerg Med 2023; 23:131-138. [PMID: 37529790 PMCID: PMC10389098 DOI: 10.4103/tjem.tjem_355_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 08/03/2023] Open
Abstract
The first-line treatment of diabetes ketoacidosis (DKA) involves fluid resuscitation with normal saline infusion to correct hypovolemia. Hyperchloremic metabolic acidosis from aggressive normal saline administration was associated with worse clinical outcomes in managing DKA. Other choices for normal saline include balanced electrolyte solutions (BESs). This study aimed to compare the clinical effects between BESs and normal saline in managing DKA. This study was a systematic review of probing articles published from inception to October 2021 in Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Google Scholar, and Scopus. Eight randomized controlled trials with a total of 595 individuals were included. The data were analyzed at 95% confidence level using random-effects models. For the primary outcomes, there was no difference in the duration of DKA resolution. (Mean difference [MD] -4.73, 95% confidence interval [CI] -2.72-4.92; I2 = 92%; P = 0.180). However, there was a significantly lower postresuscitation chloride concentration in the BES (MD 2.96 95% CI - 4.86 to - 1.06; I2 = 59%; P = 0.002). For the secondary outcomes, there was a significant reduction in duration for normalization of bicarbonate in the BES group (MD 3.11 95% CI - 3.98-2.23; I2 = 5%; P = 0.0004). There were no significant differences between groups in duration for recovery of pH, intensive unit admission, and adverse events (mortality and acute renal failure). Resuscitation with BES was associated with decreased chloride and increased bicarbonate values in DKA patients. It suggests that BES prevents DKA patients from hyperchloremic metabolic acidosis.
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Affiliation(s)
- Rozinadya Tamzil
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Normalinda Yaacob
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Norhayati Mohd Noor
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Kamarul Aryffin Baharuddin
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
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Moschopoulos CD, Dimopoulou D, Dimopoulou A, Dimopoulou K, Protopapas K, Zavras N, Tsiodras S, Kotanidou A, Fragkou PC. New Insights into the Fluid Management in Patients with Septic Shock. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1047. [PMID: 37374251 PMCID: PMC10301281 DOI: 10.3390/medicina59061047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/25/2023] [Accepted: 05/27/2023] [Indexed: 06/29/2023]
Abstract
The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The "one size fits all" approach may be "convenient" but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis.
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Affiliation(s)
- Charalampos D. Moschopoulos
- Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.D.M.); (S.T.)
| | - Dimitra Dimopoulou
- Second Department of Pediatrics, “Aghia Sophia” Children’s Hospital, 11527 Athens, Greece;
| | - Anastasia Dimopoulou
- First Department of Pediatric Surgery, “Aghia Sophia” Children’s Hospital, 11527 Athens, Greece
| | | | - Konstantinos Protopapas
- Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.D.M.); (S.T.)
| | - Nikolaos Zavras
- Department of Pediatric Surgery, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.D.M.); (S.T.)
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, Evangelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
| | - Paraskevi C. Fragkou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, Evangelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
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Jimenez JV, Garcia-Tsao G, Saffo S. Emerging concepts in the care of patients with cirrhosis and septic shock. World J Hepatol 2023; 15:497-514. [PMID: 37206653 PMCID: PMC10190696 DOI: 10.4254/wjh.v15.i4.497] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/19/2023] [Accepted: 03/23/2023] [Indexed: 04/20/2023] Open
Abstract
Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremental improvements in the diagnosis and management of septic shock in the general population, patients with cirrhosis have largely been excluded from these studies and critical knowledge gaps continue to impact the care of these individuals. In this review, we discuss nuances in the care of patients with cirrhosis and septic shock using a pathophysiology-based approach. We illustrate that septic shock may be challenging to diagnose in this population in the context of factors such as chronic hypotension, impaired lactate metabolism, and concomitant hepatic encephalopathy. Furthermore, we demonstrate that the application of routine interventions such as intravenous fluids, vasopressors, antibiotics, and steroids should be carefully considered among those with decompensated cirrhosis in light of hemodynamic, metabolic, hormonal, and immunologic disturbances. We propose that future research should include and characterize patients with cirrhosis in a systematic manner, and clinical practice guidelines may need to be refined accordingly.
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Affiliation(s)
- Jose Victor Jimenez
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520, United States
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520, United States
| | - Saad Saffo
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520, United States.
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28
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Trauzeddel RF, Leitner M, Dehé L, Nordine M, Piper SK, Habicher M, Sander M, Perka C, Treskatsch S. Goal-directed fluid therapy using uncalibrated pulse contour analysis and balanced crystalloid solutions during hip revision arthroplasty: a quality implementation project. J Orthop Surg Res 2023; 18:281. [PMID: 37024966 PMCID: PMC10078091 DOI: 10.1186/s13018-023-03738-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND To implement a goal-directed fluid therapy (GDFT) protocol using crystalloids in hip revision arthroplasty surgery within a quality management project at a tertiary hospital using a monocentric, prospective observational study. METHODS Adult patients scheduled for elective hip revision arthroplasty surgery were screened for inclusion in this prospective study. Intraoperatively stroke volume (SV) was optimized within a previously published protocol using uncalibrated pulse contour analysis and balanced crystalloids. Quality of perioperative GDFT was assessed by protocol adherence, SV increase as well as the rate of perioperative complications. Findings were then compared to two different historical groups of a former trial: one receiving GDFT with colloids (prospective colloid group) and one standard fluid therapy (retrospective control group) throughout surgery. Statistical analysis constitutes exploratory data analyses and results are expressed as median with 25th and 75th percentiles, absolute and relative frequencies, and complication rates are further given with 95% confidence intervals for proportions using the normal approximation without continuity correction. RESULTS Sixty-six patients underwent GDFT using balanced crystalloids and were compared to 130 patients with GDFT using balanced colloids and 130 controls without GDFT fluid resuscitation. There was a comparable increase in SV (crystalloids: 65 (54-74 ml; colloids: 67.5 (60-75.25 ml) and total volume infused (crystalloids: 2575 (2000-4210) ml; colloids: 2435 (1760-3480) ml; and controls: 2210 (1658-3000) ml). Overall perioperative complications rates were similar (42.4% (95%CI 30.3-55.2%) for crystalloids and 49.2% (95%CI 40.4-58.1%) for colloids and lower compared to controls: 66.9% (95%CI 58.1-74.9)). Interestingly, a reduced number of hemorrhagic complications was observed within crystalloids: 30% (95%CI 19.6-42.9); colloids: 43% (95%CI 34.4-52.0); and controls: 62% (95%CI 52.6-69.9). There were no differences in the rate of admission to the post-anesthesia care unit or intensive care unit as well as the length of stay. CONCLUSIONS Perioperative fluid management using a GDFT protocol with crystalloids in hip revision arthroplasty surgery was successfully implemented in daily clinical routine. Perioperative complications rates were reduced compared to a previous management without GDFT and comparable when using colloids. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01753050.
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Affiliation(s)
- R F Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Leitner
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - L Dehé
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Nordine
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - S K Piper
- Institute of Medical Informatics, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - M Habicher
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Germany
| | - M Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Germany
| | - C Perka
- Center for Musculoskeletal Surgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Charité Mitte and Virchow-Klinikum, Charitéplatz 1, 10117, Berlin, Germany
| | - S Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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Coen D. Fluids and vasopressors in septic shock: basic knowledge for a first approach in the emergency department. EMERGENCY CARE JOURNAL 2023. [DOI: 10.4081/ecj.2023.10810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Much research, both pathophysiological and clinical, has been produced about septic shock during the last 20 years. Nevertheless, many aspects of treatment are still controversial, among these the approach to the administration of fluids and vasopressors. After the first clinical trial on Early goal-directed therapy (EGDT) was published, a liberal approach to the use of fluids and conservative use of vasopressors prevailed, but in recent years a more restrictive use of fluids and an earlier introduction of vasopressors seem to be preferred. Although both treatments are based on sound pathophysiological knowledge, clinical evidence is still inadequate and somehow controversial. In this non-systematic review, recent research on the hemodynamics of septic shock and its treatment with fluids and inotropes is discussed. As a conclusion, general indications are proposed for a practical approach to patients in septic shock.
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Pallio S, Melita G, Shahini E, Vitello A, Sinagra E, Lattanzi B, Facciorusso A, Ramai D, Maida M. Diagnosis and Management of Esophagogastric Varices. Diagnostics (Basel) 2023; 13:diagnostics13061031. [PMID: 36980343 PMCID: PMC10047815 DOI: 10.3390/diagnostics13061031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023] Open
Abstract
Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. Thus, esophagogastric varices represent a major economic and population health issue. Patients with advanced chronic liver disease typically undergo an upper endoscopy to screen for esophagogastric varices. However, upper endoscopy is not recommended for patients with liver stiffness < 20 KPa and platelet count > 150 × 109/L as there is a low probability of high-risk varices. Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt. This article aims to offer a comprehensive review of recommendations from international guidelines as well as recent updates on the management of esophagogastric varices.
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Affiliation(s)
- Socrate Pallio
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Giuseppinella Melita
- Human Pathology of Adult and Child Department, University of Messina, 98100 Messina, Italy
| | - Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology "S. de Bellis" Research Hospital, Castellana Grotte, 70013 Bari, Italy
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Instituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Barbara Lattanzi
- Gastroenterology and Emergency Endoscopy Unit, Sandro Pertini Hospital, 00100 Rome, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, 00161 Foggia, Italy
| | - Daryl Ramai
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
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Antoniak D, Twohig P, Olson K, Samson K, Mitchell C, Eichele D. Lactated Ringer's or Normal Saline for Initial Resuscitation in Patients Hospitalized With Acute Pancreatitis: A Retrospective Database Analysis. Pancreas 2023; 52:e203-e209. [PMID: 37716004 DOI: 10.1097/mpa.0000000000002237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
OBJECTIVES Fluid resuscitation is required in acute pancreatitis (AP) to prevent hypovolemia and organ hypoperfusion. Lactated Ringer's (LR) is a buffered crystalloid with possible advantages in AP versus normal saline (NS). We aim to assess outcomes in patients hospitalized with AP based on fluid used for resuscitation. METHODS In this retrospective analysis, we identified hospital admissions to Veterans Affairs facilities for AP from 2011 to 2017 and grouped by initial resuscitation fluid: LR versus NS. Outcomes included major complications and mortality at 30 and 365 days. Multivariable models were used to adjust for confounding variables. RESULTS A total of 20,049 admissions were included in the study, of which 10% received LR as initial fluid. After adjustment for all available confounders, resuscitation with LR was associated with lower 1-year mortality compared with NS (adjusted odds ratio, 0.61 [95% confidence interval, 0.50-0.76]). Major complication and early mortality were similar between groups. CONCLUSIONS In this study, we demonstrate an association between use of LR as initial resuscitation fluid and reduced 1-year mortality in a large retrospective sample of veterans hospitalized with AP. These results support the use of LR for resuscitation for most patients hospitalized with AP.
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Affiliation(s)
| | | | | | - Kaeli Samson
- Department of Biostatistics, University of Nebraska College of Public Health, Omaha, NE
| | - Christine Mitchell
- Department of Veterans Affairs, Nebraska-Western Iowa Healthcare System, Omaha, NE
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Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup. Nat Rev Nephrol 2023; 19:401-417. [PMID: 36823168 DOI: 10.1038/s41581-023-00683-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/25/2023]
Abstract
Sepsis-associated acute kidney injury (SA-AKI) is common in critically ill patients and is strongly associated with adverse outcomes, including an increased risk of chronic kidney disease, cardiovascular events and death. The pathophysiology of SA-AKI remains elusive, although microcirculatory dysfunction, cellular metabolic reprogramming and dysregulated inflammatory responses have been implicated in preclinical studies. SA-AKI is best defined as the occurrence of AKI within 7 days of sepsis onset (diagnosed according to Kidney Disease Improving Global Outcome criteria and Sepsis 3 criteria, respectively). Improving outcomes in SA-AKI is challenging, as patients can present with either clinical or subclinical AKI. Early identification of patients at risk of AKI, or at risk of progressing to severe and/or persistent AKI, is crucial to the timely initiation of adequate supportive measures, including limiting further insults to the kidney. Accordingly, the discovery of biomarkers associated with AKI that can aid in early diagnosis is an area of intensive investigation. Additionally, high-quality evidence on best-practice care of patients with AKI, sepsis and SA-AKI has continued to accrue. Although specific therapeutic options are limited, several clinical trials have evaluated the use of care bundles and extracorporeal techniques as potential therapeutic approaches. Here we provide graded recommendations for managing SA-AKI and highlight priorities for future research.
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Hamilton LA, Behal ML, Carter AR, Rowe AS. Patient-Specific Risk Factors Associated With the Development of Hyperchloremia in a Neurocritical Care Intensive Care Unit. J Pharm Pract 2023; 36:110-116. [PMID: 34155934 DOI: 10.1177/08971900211026840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hypertonic sodium chloride (HTS) is used in intensive care unit (ICU) settings to manage cerebral edema, intracranial hypertension, and for the treatment of severe hyponatremia. It has been associated with an increased incidence of hyperchloremia; however, there is limited literature focusing on hyperchloremic risk in neurologically injured patients. Objective: The primary objective of this study was to determine risk factors associated with development of hyperchloremia in a neurocritical care (NCC) ICU population. METHODS This was a retrospective case-control study performed in an adult NCC ICU and included patients receiving HTS. The primary outcome was to evaluate patient characteristics and treatments associated with hyperchloremia. Secondary outcomes included acute kidney injury and mortality. RESULTS Overall, 133 patients were identified; patients who were hyperchloremic were considered cases (n = 100) and patients without hyperchloremia were considered controls (n = 33). Characteristics and treatments were evaluated with univariate analysis and a logistic regression model. In the multivariate model, APACHE II Score, initial serum osmolality, total 3% saline volume, and total 23.4% saline volume were significant predictors for hyperchloremia. In addition, patients with a serum chloride greater than 113.5 mEq/L were found to have a higher risk of acute kidney injury (AKI) (adjusted OR 3.15; 95% CI 1.10-9.04). CONCLUSIONS This study demonstrated APACHE II Score, initial serum osmolality, and total 3% and 23.4% saline volumes were associated with developing hyperchloremia in the NCC ICU. In addition, hyperchloremia is associated with an increased risk of AKI.
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Affiliation(s)
- Leslie A Hamilton
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
| | - Michael L Behal
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
| | - Ashley R Carter
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
| | - A Shaun Rowe
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
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Isha S, Satashia PH, Yarrarapu SNS, Govero AB, Harrison MF, Baig HZ, Guru P, Bhattacharyya A, Ball CT, Caples SM, Grek AA, Vizzini MR, Khan SA, Heise KJ, Sekiguchi H, Cantrell WL, Smith JD, Chaudhary S, Gnanapandithan K, Thompson KM, Graham CG, Cowdell JC, Murawska Baptista A, Libertin CR, Moreno Franco P, Sanghavi DK. A retrospective analysis of normal saline and lactated ringers as resuscitation fluid in sepsis. Front Med (Lausanne) 2023; 10:1071741. [PMID: 37089586 PMCID: PMC10117883 DOI: 10.3389/fmed.2023.1071741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
Background The Surviving Sepsis Campaign suggested preferential resuscitation with balanced crystalloids, such as Lactated Ringer's (LR), although the level of recommendation was weak, and the quality of evidence was low. Past studies reported an association of unbalanced solutions, such as normal saline (NS), with increased AKI risks, metabolic acidosis, and prolonged ICU stay, although some of the findings are conflicting. We have compared the outcomes with the preferential use of normal saline vs. ringer's lactate in a cohort of sepsis patients. Method We performed a retrospective cohort analysis of patients visiting the ED of 19 different Mayo Clinic sites between August 2018 to November 2020 with sepsis and receiving at least 30 mL/kg fluid in the first 6 h. Patients were divided into two cohorts based on the type of resuscitation fluid (LR vs. NS) and propensity-matching was done based on clinical characteristics as well as fluid amount (with 5 ml/kg). Single variable logistic regression (categorical outcomes) and Cox proportional hazards regression models were used to compare the primary and secondary outcomes between the 2 groups. Results Out of 2022 patients meeting our inclusion criteria; 1,428 (70.6%) received NS, and 594 (29.4%) received LR as the predominant fluid (>30 mL/kg). Patients receiving predominantly NS were more likely to be male and older in age. The LR cohort had a higher BMI, lactate level and incidence of septic shock. Propensity-matched analysis did not show a difference in 30-day and in-hospital mortality rate, mechanical ventilation, oxygen therapy, or CRRT requirement. We did observe longer hospital LOS in the LR group (median 5 vs. 4 days, p = 0.047 and higher requirement for ICU post-admission (OR: 0.70; 95% CI: 0.51-0.96; p = 0.026) in the NS group. However, these did not remain statistically significant after adjustment for multiple testing. Conclusion In our matched cohort, we did not show any statistically significant difference in mortality rates, hospital LOS, ICU admission after diagnosis, mechanical ventilation, oxygen therapy and RRT between sepsis patients receiving lactated ringers and normal saline as predominant resuscitation fluid. Further large-scale prospective studies are needed to solidify the current guidelines on the use of balanced crystalloids.
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Affiliation(s)
- Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | | | - Austin B. Govero
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Michael F. Harrison
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Hassan Z. Baig
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Pramod Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - Colleen T. Ball
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, United States
| | - Sean M. Caples
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ami A. Grek
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Michael R. Vizzini
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Syed Anjum Khan
- Department of Critical Care Medicine, Mayo Clinic Health System Mankato, Mankato, MN, United States
| | - Katherine J. Heise
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Hiroshi Sekiguchi
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, United States
| | - Warren L. Cantrell
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Jeffrey D. Smith
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | | | - Charles G. Graham
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Jed C. Cowdell
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - Claudia R. Libertin
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL, United States
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Devang K. Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: Devang K. Sanghavi,
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35
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Messina A, Bakker J, Chew M, De Backer D, Hamzaoui O, Hernandez G, Myatra SN, Monnet X, Ostermann M, Pinsky M, Teboul JL, Cecconi M. Pathophysiology of fluid administration in critically ill patients. Intensive Care Med Exp 2022; 10:46. [PMID: 36329266 PMCID: PMC9633880 DOI: 10.1186/s40635-022-00473-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Fluid administration is a cornerstone of treatment of critically ill patients. The aim of this review is to reappraise the pathophysiology of fluid therapy, considering the mechanisms related to the interplay of flow and pressure variables, the systemic response to the shock syndrome, the effects of different types of fluids administered and the concept of preload dependency responsiveness. In this context, the relationship between preload, stroke volume (SV) and fluid administration is that the volume infused has to be large enough to increase the driving pressure for venous return, and that the resulting increase in end-diastolic volume produces an increase in SV only if both ventricles are operating on the steep part of the curve. As a consequence, fluids should be given as drugs and, accordingly, the dose and the rate of administration impact on the final outcome. Titrating fluid therapy in terms of overall volume infused but also considering the type of fluid used is a key component of fluid resuscitation. A single, reliable, and feasible physiological or biochemical parameter to define the balance between the changes in SV and oxygen delivery (i.e., coupling “macro” and “micro” circulation) is still not available, making the diagnosis of acute circulatory dysfunction primarily clinical. Fluids are drugs used in patients with shock to increase the cardiac output with the aim to improve oxygen delivery to the cells. The response to fluid administration is determined by the physiological interaction of cardiac function and venous return. In septic shock, the beneficial clinical response of fluid administration is rapidly reduced after few hours and fluid titration is crucial to avoid detrimental fluid overload. The fluid challenge is a fluid bolus given at a defined quantity and rate to assess fluid responsiveness. The ideal fluid for critically ill patients does not exist; however, crystalloids should be used as first choice. Balanced crystalloid solutions may be associated with better outcomes but the evidence is still low. Albumin infusion may have a role in already fluid resuscitated patients at risk of fluid overload. Fluid administration is integrated into the complex management of pressure and flow “macro” hemodynamic variables, coupled to the “micro” local tissue flow distribution and regional metabolism. Macro-variables are managed by measuring systemic blood pressure and evaluating the global cardiac function. The critical threshold of oxygen delivery to the cells is difficult to estimate, however, several indexes and clinical signs may be considered as surrogate of that, and integrated in a decision-making process at the bedside.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
| | - Jan Bakker
- NYU Langone Health and Columbia University Irving Medical Center, New York, USA.,Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Michelle Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Olfa Hamzaoui
- Service de Reanimation PolyvalenteHopital Antoine Béclère, Hopitaux Universitaires Paris-Saclay, Clamart, France
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, Paris, France
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, Paris, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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36
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Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, Jovanovic I, Awadie H, Hernandez-Gea V, Tantau M, Ebigbo A, Ibrahim M, Vlachogiannakos J, Burgmans MC, Rosasco R, Triantafyllou K. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:1094-1120. [PMID: 36174643 DOI: 10.1055/a-1939-4887] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Marine Camus Duboc
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA) & Assistance Publique-Hôpitaux de Paris (AP-HP), Endoscopic Center, Saint Antoine Hospital, Paris, France
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCSS-S. Orsola-Malpighi, Hospital, Bologna, Italy
| | - John Gásdal Karstensen
- Gastroenterology Unit, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tomas Hucl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Jovanovic
- Euromedik Health Care System, Visegradska General Hospital, Belgrade, Serbia
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Marcel Tantau
- University of Medicine and Pharmacy 'Iuliu Hatieganu' Cluj-Napoca, Romania
| | - Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Jiannis Vlachogiannakos
- Academic Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Marc C Burgmans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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Dietrich M, Beynon C, Fiedler MO, Bernhard M, Hecker A, Jungk C, Nusshag C, Michalski D, Schmitt FCF, Brenner T, Weigand MA, Reuß CJ. [Focus general intensive care medicine 2021/2022 : Summary of selected intensive care studies]. DIE ANAESTHESIOLOGIE 2022; 71:714-721. [PMID: 35925182 DOI: 10.1007/s00101-022-01173-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 06/15/2023]
Affiliation(s)
- M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - A Hecker
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - F C F Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
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Catahay JA, Polintan ET, Casimiro M, Notarte KI, Velasco JV, Ver AT, Pastrana A, Macaranas I, Patarroyo-Aponte G, Lo KB. Balanced electrolyte solutions versus isotonic saline in adult patients with diabetic ketoacidosis: A systematic review and meta-analysis. Heart Lung 2022; 54:74-79. [PMID: 35358905 DOI: 10.1016/j.hrtlng.2022.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Current guidelines suggest the use of isotonic saline (IS) infusion as the preferred resuscitation fluid in the management of diabetic ketoacidosis (DKA). However, balanced electrolyte solutions (BES) have been proposed as an alternative due to a lower propensity to cause hyperchloremic metabolic acidosis. Evidence regarding the use of BES in DKA remains limited. OBJECTIVES To determine if the use of BES in fluid resuscitation leads to faster resolution of DKA compared to IS. METHODS The study involves a comprehensive search of literature from PubMed, Cochrane CENTRAL, Google Scholar, and Science Direct of clinical trials addressing the use of BES vs IS in fluid resuscitation in DKA. The time to resolution of DKA was examined as the primary endpoint. Pooled hazard ratios (HR) and Mean Difference (MD) in hours with their 95% confidence intervals (CI) were calculated using a random-effects model. RESULTS The literature search included 464 studies that were screened individually. A total of 9 studies were identified but 6 studies were excluded due to irrelevance in the outcome of interest and target population. The pooled hazard ratio HR significantly revealed 1.46 [1.10 to 1.94] (p = 0.009) with 12% heterogeneity while MD was -3.02 (95% CI -6.78-0.74; p = 0.12) with heterogeneity of 85%. CONCLUSION Considering the evidence from pooled small randomized trials with moderate overall certainty of evidence, the use of BES in DKA was associated with faster rates of DKA resolution compared to IS.
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Affiliation(s)
| | | | - Michael Casimiro
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Kin Israel Notarte
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | | | | | - Adriel Pastrana
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Imee Macaranas
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Gabriel Patarroyo-Aponte
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, USA
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39
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Kalkman LC, Hänscheid T, Krishna S, Grobusch MP. Fluid therapy for severe malaria. THE LANCET. INFECTIOUS DISEASES 2022; 22:e160-e170. [PMID: 35051406 DOI: 10.1016/s1473-3099(21)00471-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/20/2021] [Accepted: 07/28/2021] [Indexed: 06/14/2023]
Abstract
Fluid therapy is an important supportive measure for patients with severe malaria. Patients with severe malaria usually have normal cardiac index, vascular resistance, and blood pressure and a small degree of hypovolaemia due to dehydration. Cell hypoxia, reduced kidney function, and acidosis result from microcirculatory compromise and malarial anaemia, which reduce tissue oxygenation, not hypovolaemia. Hence, aggressive fluid loading does not correct acid-base status, enhance kidney function, or improve patient outcomes, and it risks complications such as pulmonary oedema. Individualised conservative fluid management is recommended in patients with severe malaria. Physical examination and physiological indices have limited reliability in guiding fluid therapy. Invasive measures can be more accurate than physical examination and physiological indices but are often unavailable in endemic areas, and non-invasive measures, such as ultrasound, are mostly unexplored. Research into reliable methods applicable in low-resource settings to measure fluid status and response is a priority. In this Review, we outline the current knowledge on fluid management in severe malaria and highlight research needed to optimise fluid therapy and improve survival in severe malaria.
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Affiliation(s)
- Laura C Kalkman
- Centre of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centre, Department of Infectious Diseases, University of Amsterdam, Amsterdam, Netherlands; Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon
| | - Thomas Hänscheid
- Instituto de Microbiologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Sanjeev Krishna
- Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon; Clinical Academic Group, Institute for Infection and Immunity, and St George's University Hospitals NHS Foundation Trust, St George's University of London, London, UK; Institut für Tropenmedizin, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Martin P Grobusch
- Centre of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centre, Department of Infectious Diseases, University of Amsterdam, Amsterdam, Netherlands; Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon; Institut für Tropenmedizin, Universitätsklinikum Tübingen, Tübingen, Germany; Masanga Medical Research Unit, Masanga, Sierra Leone; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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40
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Jin X, Li J, Ren J, Gao Y, Li R, Zhang J, Wang X, Wang G. Effect of initial serum chloride level on the association between intravenous chloride load and mortality in critically ill patients: A retrospective cohort study. J Crit Care 2022; 69:154002. [DOI: 10.1016/j.jcrc.2022.154002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 11/26/2022]
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Abstract
The definition of sepsis has evolved significantly over the past three decades. Today, sepsis is defined as a dysregulated host immune response to microbial invasion leading to end organ dysfunction. Septic shock is characterized by hypotension requiring vasopressors after adequate fluid resuscitation with elevated lactate. Early recognition and intervention remain hallmarks for sepsis management. We addressed the current literature and assimilated thought regarding optimum initial resuscitation of the patient with sepsis. A nuanced understanding of the physiology of lactate is provided in our review. Physiologic and practical knowledge of steroid and vasopressor therapy for sepsis is crucial and addressed. As blood purification may interest the nephrologist treating sepsis, we have also added a brief discussion of its status.
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Affiliation(s)
- Sharad Patel
- Department of Critical Care, Rowan University Cooper Medical School, Camden, New Jersey
| | - Nitin Puri
- Department of Critical Care, Cooper Hospital University Medical Center, Camden, New Jersey
| | - R Phillip Dellinger
- Department of Critical Care, Cooper Hospital University Medical Center, Camden, New Jersey
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Marchiset A, Jamme M. When the Renal (Function) Begins to Fall: A Mini-Review of Acute Kidney Injury Related to Acute Respiratory Distress Syndrome in Critically Ill Patients. FRONTIERS IN NEPHROLOGY 2022; 2:877529. [PMID: 37675005 PMCID: PMC10479595 DOI: 10.3389/fneph.2022.877529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/21/2022] [Indexed: 09/08/2023]
Abstract
Acute kidney injury (AKI) is one of the most frequent causes of organ failure encountered in patients in the intensive care unit (ICU). Because of its predisposition to occur in the most critically ill patients, it is not surprising to observe a high frequency of AKI in patients with acute respiratory distress syndrome (ARDS). However, few studies have been carried out to assess the epidemiology of AKI in subgroups of ARDS patients using recommended KDIGO criteria. Moreover, the mechanisms involved in the physio-pathogenesis of AKI are still poorly understood, in particular the impact of mechanical ventilation on the kidneys. We carried out a review of the literature, focusing on the epidemiology and physiopathology of AKI in patients with ARDS admitted to the ICU. We addressed the importance of clinical management, focusing on mechanical ventilation for improving outcomes, on AKI. Finally, we also propose candidate treatment strategies and management perspectives. Our literature search showed that AKI is particularly common in ICU patients with ARDS. In association with the classic risk factors for AKI, such as comorbidities and iatrogeny, changes in mechanical ventilation parameters, which have been exclusively evaluated for their outcomes on respiratory function and death, must be considered carefully in terms of their impact on the short-term renal prognosis.
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Affiliation(s)
- Antoine Marchiset
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Poissy-Saint Germain en Laye, Poissy, France
| | - Matthieu Jamme
- Service de Réanimation, Hôpital Privé de l’Ouest Parisien, Ramsay Générale de Santé, Trappes, France
- INSERM UMR 1018, Equipe Epidémiologie Clinique, CESP, Villejuif, France
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Dong WH, Yan WQ, Song X, Zhou WQ, Chen Z. Fluid resuscitation with balanced crystalloids versus normal saline in critically ill patients: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2022; 30:28. [PMID: 35436929 PMCID: PMC9013977 DOI: 10.1186/s13049-022-01015-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/08/2022] [Indexed: 11/20/2022] Open
Abstract
Background Intravenous fluids are used commonly for almost all intensive care unit (ICU) patients, especially for patients in need of resuscitation. The selection and use of resuscitation fluids may affect the outcomes of patients; however, the optimal resuscitative fluid remains controversial. Methods We systematically searched PubMed, Embase, and CENTRAL. Studies comparing balanced crystalloids and normal saline in ICU patients were selected. We used the Cochrane Collaboration tool to assess the risk of bias in studies. The primary outcome was mortality at the longest follow-up. Secondary outcomes included the incidence of acute kidney injury (AKI) and new renal replacement therapy (RRT). Results A total of 35,456 patients from eight studies were included. There was no significant difference between balanced crystalloid solutions and saline in mortality (risk ratio [RR]: 0.96; 95% confidence interval [CI]:0.92–1.01). The subgroup analysis with traumatic brain injury (TBI) showed lower mortality in patients receiving normal saline (RR:1.25; 95% CI 1.02–1.54). However, in patients with non-TBI, balanced crystalloid solutions achieved lower mortality than normal saline (RR: 0.94; 95% CI 0.90–0.99). There was no significant difference in moderate to severe AKI (RR: 0.96; 95% CI 0.90–1.01) or new RRT (RR: 0.94; 95% CI 0.84–1.04). Conclusions Compared with normal saline, balanced crystalloids may not improve the outcomes of mortality, the incidence of AKI, and the use of RRT for critically ill patients. However, balanced crystalloids reduce the risk of death in patients with non-TBI but increase the risk of death in those with TBI. Large-scale rigorous randomized trials with better designs are needed, especially for specific patient populations. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01015-3.
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Beran A, Altorok N, Srour O, Malhas SE, Khokher W, Mhanna M, Ayesh H, Aladamat N, Abuhelwa Z, Srour K, Mahmood A, Altorok N, Taleb M, Assaly R. Balanced Crystalloids versus Normal Saline in Adults with Sepsis: A Comprehensive Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11071971. [PMID: 35407578 PMCID: PMC8999853 DOI: 10.3390/jcm11071971] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 02/08/2023] Open
Abstract
The crystalloid fluid of choice in sepsis remains debatable. We aimed to perform a comprehensive meta-analysis to compare the effect of balanced crystalloids (BC) vs. normal saline (NS) in adults with sepsis. A systematic search of PubMed, EMBASE, and Web of Sciences databases through 22 January 2022, was performed for studies that compared BC vs. NS in adults with sepsis. Our outcomes included mortality and acute kidney injury (AKI), need for renal replacement therapy (RRT), and ICU length of stay (LOS). Pooled risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were obtained using a random-effect model. Fifteen studies involving 20,329 patients were included. Overall, BC showed a significant reduction in the overall mortality (RR 0.88, 95% CI 0.81-0.96), 28/30-day mortality (RR 0.87, 95% CI 0.79-0.95), and AKI (RR 0.85, 95% CI 0.77-0.93) but similar 90-day mortality (RR 0.96, 95% CI 0.90-1.03), need for RRT (RR 0.91, 95% CI 0.76-1.08), and ICU LOS (MD -0.25 days, 95% CI -3.44, 2.95), were observed between the two groups. However, subgroup analysis of randomized controlled trials (RCTs) showed no statistically significant differences in overall mortality (RR 0.92, 95% CI 0.82-1.02), AKI (RR 0.71, 95% CI 0.47-1.06), and need for RRT (RR 0.71, 95% CI 0.36-1.41). Our meta-analysis demonstrates that overall BC was associated with reduced mortality and AKI in sepsis compared to NS among patients with sepsis. However, subgroup analysis of RCTs showed no significant differences in both overall mortality and AKI between the groups. There was no significant difference in the need for RRT or ICU LOS between BC and NS. Pending further data, our study supports using BC over NS for fluid resuscitation in adults with sepsis. Further large-scale RCTs are necessary to validate our findings.
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Affiliation(s)
- Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Correspondence: ; Tel.: +1-469-348-1347
| | - Nehaya Altorok
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Omar Srour
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Saif-Eddin Malhas
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Mohammed Mhanna
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Hazem Ayesh
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nameer Aladamat
- Department of Neurology, University of Toledo, Toledo, OH 43606, USA;
| | - Ziad Abuhelwa
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Khaled Srour
- Department of Critical Care Medicine, Henry Ford Health System, Detroit, MI 48202, USA;
| | - Asif Mahmood
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nezam Altorok
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Department of Rheumatology, University of Toledo, Toledo, OH 43606, USA
| | - Mohammad Taleb
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH 43606, USA;
| | - Ragheb Assaly
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH 43606, USA;
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Jung S, Kim J, Lee J, Choi SY, Joo HJ, Koo BN. Effects of the Type of Intraoperative Fluid in Living Donor Kidney Transplantation: A Single-Center Retrospective Cohort Study. Yonsei Med J 2022; 63:380-388. [PMID: 35352890 PMCID: PMC8965431 DOI: 10.3349/ymj.2022.63.4.380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 11/23/2021] [Accepted: 12/11/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Perioperative fluid management in kidney transplant recipients is crucial to supporting the fluid, acid-base, and electrolyte balance required for graft perfusion. However, the choice of intraoperative crystalloids in kidney transplantation remains controversial. We conducted a single-center retrospective cohort study to evaluate the impact of intraoperative fluids on acid-base and electrolyte balance and graft outcomes. MATERIALS AND METHODS We included 282 living donor kidney transplant recipients from January 2010 to December 2017. Patients were classified into two groups based on the type of intraoperative crystalloids used (157 patients in the half saline group and 125 patients in the balanced crystalloid solutions group, Plasma-lyte). RESULTS Compared with the half saline group, the Plasma-lyte group showed less metabolic acidosis and hyponatremia during surgery. Hyperkalemia incidence was not significantly different between the two groups. Changes in postoperative graft function assessed by blood urea nitrogen and creatinine were significantly different between the two groups. Patients in the Plasma-lyte group exhibited consistently higher glomerular filtration rates than those in the half saline group at 1 month and 1 year after transplantation after adjusting for demographic differences. CONCLUSION Intraoperative Plasma-lyte can lead to more favorable results in terms of acid-base balance during kidney transplantation. Patients who received Plasma-lyte showed superior postoperative graft function at 1 month and 1 year after transplantation. Further studies are needed to evaluate the superiority of intraoperative Plasma-lyte over other types of crystalloids in relation to graft outcomes.
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Affiliation(s)
- Seungho Jung
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Su Youn Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Ji Joo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Critical Care in Obstetrics. Best Pract Res Clin Anaesthesiol 2022; 36:209-225. [DOI: 10.1016/j.bpa.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/20/2022]
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Wang M, Zhu B, Jiang L, Luo X, Wang N, Zhu Y, Xi X. Association between Latent Trajectories of Fluid Balance and Clinical Outcomes in Critically Ill Patients with Acute Kidney Injury: A Prospective Multicenter Observational Study. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:82-92. [PMID: 35224009 PMCID: PMC8820145 DOI: 10.1159/000515533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 02/26/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION We aimed to identify different trajectories of fluid balance (FB) and investigate the effect of FB trajectories on clinical outcomes in intensive care unit (ICU) patients with acute kidney injury (AKI) and the dose-response association between fluid overload (FO) and mortality. METHODS We derived data from the Beijing Acute Kidney Injury Trial (BAKIT). A total of 1,529 critically ill patients with AKI were included. The primary outcome was 28-day mortality, and hospital mortality, ICU mortality and AKI stage were the secondary outcomes. A group-based trajectory model was used to identify the trajectory of FB during the first 7 days. Multivariable logistic regression was performed to examine the relationship between FB trajectories and clinical outcomes. A logistic regression model with restricted cubic splines was used to examine the dose relationship between FO and 28-day mortality. RESULTS Three distinct trajectories of FB were identified: low FB (1,316, 86.1%), decreasing FB (120, 7.8%), and high FB (93, 6.1%). Compared with low FB, high FB was associated with increased 28-day mortality (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.17-3.19) and AKI stage (OR 2.04, 95% CI 1.23-3.37), whereas decreasing FB was associated with a reduction in 28-day mortality by approximately half (OR 0.53, 95% CI 0.32-0.87). Similar results were found for the outcomes of ICU mortality and hospital mortality. We observed a J-shaped relationship between maximum FO and 28-day mortality, with the lowest risk at a maximum FO of 2.8% L/kg. CONCLUSION Different trajectories of FB in critically ill patients with AKI were associated with clinical outcomes. An FB above or below a certain range was associated with an increased risk of mortality. Further studies should explore this relationship and search for the optimal fluid management strategies for critically ill patients with AKI.
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Affiliation(s)
- Meiping Wang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Bo Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Li Jiang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuying Luo
- Department of Critical Care Medicine, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Na Wang
- Emergency Department, China Rehabilitation Research Center, Capital Medical University, Beijing, China
| | - Yibing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
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Barlow B, Bissell BD. Evaluation of Evidence, Pharmacology, and Interplay of Fluid Resuscitation and Vasoactive Therapy in Sepsis and Septic Shock. Shock 2021; 56:484-492. [PMID: 33756502 DOI: 10.1097/shk.0000000000001783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT We sought to review the pharmacology of vasoactive therapy and fluid administration in sepsis and septic shock, with specific insight into the physiologic interplay of these agents. A PubMed/MEDLINE search was conducted using the following terms (vasopressor OR vasoactive OR inotrope) AND (crystalloid OR colloid OR fluid) AND (sepsis) AND (shock OR septic shock) from 1965 to October 2020. A total of 1,022 citations were reviewed with only relevant clinical data extracted. While physiologic rationale provides a hypothetical foundation for interaction between fluid and vasopressor administration, few studies have sought to evaluate the clinical impact of this synergy. Current guidelines are not in alignment with the data available, which suggests a potential benefit from low-dose fluid administration and early vasopressor exposure. Future data must account for the impact of both of these pharmacotherapies when assessing clinical outcomes and should assess personalization of therapy based on the possible interaction.
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Affiliation(s)
- Brooke Barlow
- Department of Pharmacy, University of Kentucky, Lexington, Kentucky
- College of Pharmacy, Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
| | - Brittany D Bissell
- Department of Pharmacy, University of Kentucky, Lexington, Kentucky
- College of Pharmacy, Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
- College of Medicine, Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, Kentucky
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Li H, Bersten A, Wiersema U, Schembri D, Cavallaro E, Dixon DL, Bihari S. Bolus intravenous 0.9% saline leads to interstitial permeability pulmonary edema in healthy volunteers. Eur J Appl Physiol 2021; 121:3409-3419. [PMID: 34480632 DOI: 10.1007/s00421-021-04805-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Bolus intravenous administration of 0.9% saline has been associated with the development of pulmonary edema, and increased mortality. An animal model has previously demonstrated that rapid intravenous administration of 0.9% saline was associated with non-hydrostatic lung injury with increased lung lavage protein. We hypothesized that this non-hydrostatic effect would also occur in human volunteers. METHODS In a randomized, cross-over study of 14 healthy male subjects, the lung lavage protein concentration and cardiorespiratory effects of an intervention with rapid intravenous administration of 30 mL/kg of 0.9% saline were compared with sham intervention. Bronchoalveolar lavage (BAL) was performed after fluid administration. Doppler echocardiography, lung ultrasound, pulmonary function tests, and blood sampling were performed before and after each intervention. RESULTS The BAL total protein concentration was greater after 0.9% saline administration than with sham (196.1 µg/mL (SD 87.6) versus 129.8 µg/mL (SD 55.4), respectively (p = 0.020). Plasma angiopoietin-2 concentration was also increased to 2.26 ng/mL (SD 0.87) after 0.9% saline administration compared with sham 1.53 ng/mL (SD 0.69) (p < 0.001). There were small increases in stroke volume (from 58 mL (IQR 51-74) to 66 mL (IQR 58-74), p = 0.045) and Doppler echocardiography left ventricle E/e' ratio (from 5.0 (IQR 4.5-6.0) to 5.7 (IQR 5.3-6.3), p = 0.007), but no changes to right ventricular function. CONCLUSION Rapid intravenous administration of 0.9% saline leads to interstitial permeability pulmonary edema in healthy human volunteers. Further research is now warranted to understand these effects in critically ill patients.
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Affiliation(s)
- Hanmo Li
- Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, SA, 5042, Australia.
| | - Andrew Bersten
- Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, SA, 5042, Australia.,Department of Critical Care Medicine, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Ubbo Wiersema
- Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, SA, 5042, Australia
| | - David Schembri
- Respiratory Functions Laboratory, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Elena Cavallaro
- Department of Critical Care Medicine, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Dani-Louise Dixon
- Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, SA, 5042, Australia.,Department of Critical Care Medicine, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Shailesh Bihari
- Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, SA, 5042, Australia.,Department of Critical Care Medicine, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Bernal W, Karvellas C, Saliba F, Saner FH, Meersseman P. Intensive care management of acute-on-chronic liver failure. J Hepatol 2021; 75 Suppl 1:S163-S177. [PMID: 34039487 DOI: 10.1016/j.jhep.2020.10.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
The syndrome of acute-on-chronic liver failure combines deterioration of liver function in a patient with chronic liver disease, with the development of extrahepatic organ failure and high short-term mortality. Its successful management demands a rapid and coherent response to the development of dysfunction and failure of multiple organ systems in an intensive care unit setting. This response recognises the features that distinguish it from other critical illness and addresses the complex interplay between the precipitating insult, the many organ systems involved and the disordered physiology of underlying chronic liver disease. An evidence base is building to support the approaches currently adopted and outcomes for patients with this condition are improving, but mortality remains unacceptably high. Herein, we review practical considerations in critical care management, as well as discussing key knowledge gaps and areas of controversy that require further focussed research.
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
| | - Constantine Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris SACLAY, INSERM Unit 1193, Villejuif, France
| | - Fuat H Saner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum Essen Hufelandstr. 55 45 147, Essen, Germany
| | - Philippe Meersseman
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium
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